Impact of Service-Based Student Loan Repayment Program on the Primary Care Workforce.

PURPOSE: As the average level of medical education indebtedness rises, physicians look to programs such as Public Service Loan Forgiveness (PSLF) and National Health Service Corps (NHSC) to manage debt burden. Both represent service-dependent loan repayment programs, but the requirements and program outcomes diverge, and assessing the relative uptake of each program may help to inform health workforce policy decisions. We sought to describe variation in the composition of repayment program participant groups and measure relative impact on patient access to care. METHODS: In this bivariate analysis, we analyzed data from 10,677 respondents to the American Board of Family Medicine's National Graduate Survey to study differences in loan repayment program uptake as well as the unique participant demographics, scope of practice, and likelihood of practicing with a medically underserved or rural population in each program cohort. RESULTS: The rate of PSLF uptake tripled between 2016 and 2020, from 7% to 22% of early career family physicians, while NHSC uptake remained static at 4% to 5%. Family physicians reporting NHSC assistance were more likely than those reporting PSLF assistance to come from underrepresented groups, demonstrated a broader scope of practice, and were more likely to practice in rural areas (23.3% vs 10.8%) or whole-county Health Professional Shortage Areas (12.5% vs 3.7%) and with medically underserved populations (82.2% vs 24.2%). CONCLUSIONS: Although PSLF supports family physicians intending to work in public service, their peers who choose NHSC are much more likely to work in underserved settings. Our findings may prompt a review of the goals of service loan forgiveness programs with potential to better serve health workforce needs.

Characteristics of Family Physicians Practicing Collaboratively With Behavioral Health Professionals.

Integrating behavioral health into primary care can improve access to behavioral health and patient health outcomes. We used 2017-2021 American Board of Family Medicine continuing certificate examination registration questionnaire responses to determine the characteristics of family physicians who work collaboratively with behavioral health professionals. With a 100% response rate, 38.8% of 25,222 family physicians reported working collaboratively with behavioral health professionals, with those working in independently owned practices and in the South having substantially lower rates. Future research exploring these differences could help develop strategies to support family physicians implement integrated behavioral health to improve care for patients in these communities.

Research interests of family physicians applying for research training.

BACKGROUND: There is an ongoing need for research to support the practice of high quality family medicine. The Family Medicine Discovers Rapid Cycle Scientific Discovery and Innovation (FMD RapSDI) program is designed to build capacity for family medicine scientific discovery and innovation in the United States. Our objective was to describe the applicants and research questions submitted to the RapSDI program in 2019 and 2020. METHODS: Descriptive analysis for applicant characteristics and rapid qualitative analysis using principles of grounded theory and content analysis to examine the research questions and associated themes. We examined differences by year of application submission and the applicant's career stage. RESULTS: Sixty-five family physicians submitted 70 applications to the RapSDI program; 45 in 2019 and 25 in 2020. 41% of applicants were in practice for five years or less (n = 27), 18% (n = 12) were in in practice 6-10 years, and 40% (n = 26) were ≥ 11 years in practice. With significant diversity in questions, the most common themes were studies of new innovations (n = 20, 28%), interventions to reduce cost (n = 20, 28%), improving screening or diagnosis (n = 19, 27%), ways to address mental or behavioral health (n = 18, 26%), and improving care for vulnerable populations (n = 18, 26%). CONCLUSION: Applicants proposed a range of research questions and described why family medicine is optimally suited to address the questions. Applicants had a desire to develop knowledge to help other family physicians, their patients, and their communities. Findings from this study can help inform other family medicine research capacity building initiatives.

Family Practices in Transforming Clinical Practice Initiative Showed No Changes in Medicare Costs or Utilization.

BACKGROUND: The Centers for Medicare and Medicaid Services proposed that the Transforming Clinical Practice Initiative (TCPI) would improve health outcomes for patients, reduce utilization of institutional services, and generate significant savings for payers by the end of September 2019. OBJECTIVE: The objective of this study was to investigate whether participation in TCPI's Practice Transformation Networks (PTNs) was associated with improved cost and utilization outcomes for Medicare patients of family medicine-based practices in the first 2 years, that is, 2016-2017, of the Initiative. STUDY DESIGN: A quasi-experimental design with a longitudinal cohort of family medicine-based practices and a propensity-matched comparison sample. SUBJECTS: A total of 761 PTN practices and 3451 non-PTN practices. MEASURES: To measure practice-level patient outcomes, we attributed patients to practice based on the plurality of office visits. We obtained Medicare claims from 2011 to 2017 to assess PTN participation effects for Medicare Part A and B costs, hospital admission, and emergency department visit rates using a Difference-in-Differences design, adjusting for baseline characteristics. RESULTS: The differences in Medicare Part A and B costs (-1.71%, P=0.25), annual rates of hospitalization (-0.59%, P=0.12) and emergency department visit (-0.29%, P=0.46) were not significantly lower among PTN practices (N=761) than among propensity score-matched non-PTN practices (N=3541). CONCLUSIONS: TCPI's transforming efforts, such as the outcomes examined in the study, might need a longer time frame to manifest and require evaluation after the full 4-year participation period. The indistinguishable effect of PTN participation may also be attributed to the fact that non-PTN practices might have participated in other initiatives that changed their care and curbed health care utilization and costs consequently.

Physicians' Choice of Board Certification Activity Is Unaffected by Baseline Quality of Care: The TRADEMaRQ Study.

PURPOSE: Physicians' use of self-assessment to guide quality improvement or board certification activities often does not correlate with more objective measures, and they may spend valuable time on activities that support their strengths instead of addressing gaps. Our objective was to study whether viewing quality measures, with peer comparisons, would affect the selection of certification activities. METHODS: We conducted a cluster-randomized controlled trial-the Trial of Data Exchange for Maintenance of certification and Raising Quality (TRADEMaRQ)-with 4 partner organizations during 2015-2017. Physicians were presented their quality data within their online certification portfolios before (intervention) vs after (control) they chose board certification activities. The primary outcome was whether the selected activity addressed a quality gap (a quality area in which the physician scored below the mean for the study population). RESULTS: Of 2,570 invited physicians, 254 physicians completed the study: 130 in the intervention group and 124 in the control group. Nearly one-fifth of participating physicians did not complete any certification activities during the study. A sizable minority of those in the intervention group, 18.4%, never reviewed their quality dashboard. Overall, just 27.2% of completed certification activities addressed a quality gap, and there was no significant difference in this outcome in the intervention group vs the control group in either bivariate or adjusted analyses (odds ratio = 1.28; 95% CI, 0.90-1.82). CONCLUSIONS: Physicians did not use quality performance data in choosing certification activities. Certification boards are being pressed to make their programs relevant to practice, less burdensome, and supportive of quality improvement in alignment with value-based payment models. Using practice data to drive certification choices would meet these goals.

Harmonized Outcome Measures for Use in Depression Patient Registries and Clinical Practice.

Major depressive disorder is a common mental health condition that affects an estimated 16.2 million adults and 3.1 million adolescents in the United States. Yet, a lack of uniformity remains in measurements and monitoring for depression both in clinical practice and in research settings. This project aimed to develop a minimum set of standardized outcome measures relevant to both patients and clinicians that can be collected in depression registries and clinical practice. Twenty-nine depression registries and related data collection efforts were identified and invited to submit outcome measures. Additional measures were identified through literature searches and reviews of quality measures. A multistakeholder panel representing clinicians; payers; government agencies; industry; and medical specialty, health care quality, and patient advocacy organizations categorized the 27 identified measures using the Agency for Healthcare Research and Quality's supported Outcome Measures Framework. The panel identified 10 broadly relevant measures and harmonized definitions for these measures through in-person and virtual meetings. The harmonized measures represent a minimum set of outcomes that are relevant to clinicians and patients and appropriate for use in depression research and clinical practice. Routine and consistent collection of these measures in registries and other systems would support creation of a national research infrastructure to efficiently address new questions, improve patient management and outcomes, and facilitate care coordination.

Characteristics of Family Medicine Residency Graduates, 1994-2017: An Update.

PURPOSE: The purpose of this study was to characterize graduates of family medicine (FM) residencies from 1994 to 2017 and determine whether they continue to practice family medicine after residency. METHOD: We sampled physicians who completed FM residency training from 1994-2017 using 2017 American Medical Association (AMA) Physician Masterfile linked with administrative files of the American Board of Family Medicine (ABFM). The main outcomes measured were characteristics of FM residency graduates, including medical degree type (Doctor of Medicine, MD vs Doctor of Osteopathic Medicine, DO), international medical school graduates (IMGs) vs US graduates, sex, ABFM certification status, and self-designated primary specialty. Family medicine residency graduates were grouped into 4-year cohorts by year of residency completion. RESULTS: From 1994 to 2017, 66,778 residents completed training in an ACGME accredited FM residency, averaging 2,782 graduates per year. The number of FM residency graduates peaked in 1998-2001, averaging 3,053 each year. The composition of FM residents diversified with large increases in DOs, IMGs, and female graduates over the past 24 years. Of all the FM residency graduates, 91.9% claimed FM as their primary specialty and 81% were certified with ABFM in 2017. FM/sport medicine (2.1%), FM/geriatric medicine (0.9%), internal medicine/geriatrics (0.8%), and emergency medicine (0.7%) were the most common non-FM primary specialties reported. CONCLUSIONS: DOs, IMGs, and female family medicine residency graduates increased from 1994 to 2017. With 9 in 10 graduates of family medicine residencies designating FM as their primary specialty, FM residency programs not only train but supply family physicians who are likely to remain in the primary care workforce.

General Practitioners in US Medical Practice Compared With Family Physicians.

PURPOSE: General practitioners (GPs) are part of the US physician workforce, but little is known about who they are, what they do, and how they differ from family physicians (FPs). We describe self-identified GPs and compare them with board-certified FPs. METHODS: Analysis of data on 102,604 Doctor of Medicine and Doctor of Osteopathy physicians in direct patient care in the United States in 2016, who identify themselves as GPs or FPs. The study used linking databases (American Medical Association Masterfile, American Board of Family Medicine [ABFM], Area Health Resource File, Medicare Public Use File) to examine personal, professional, and practice characteristics. RESULTS: Of the physicians identified, 6,661 self-designated as GPs and 95,943 self-designated as FPs. Of the self-designated GPs, 116 had been ABFM certified and were excluded from the study. Of the remaining 102,488 physicians, those who self-designated as GPs but were never ABFM certified constituted the GP group (n = 6,545, 6%). Self-designated FPs that were ABFM certified made up the FP group (n = 79,449, 78%). The remaining self-designated FPs not ABFM certified constituted the uncertified group (n = 16,494, 16%). GPs differed from FPs in every characteristic examined. Compared with FPs, GPs are more likely to be older, male, Doctors of Osteopathy, graduates of non-US medical schools, and have no family medicine residency training. GPs practice location is similar to FPs, but GPs are less likely to participate in Medicare or to work in hospitals. CONCLUSIONS: GPs in the United States are a varied group that differ from FPs. Researchers, educators, and policy makers should not lump GPs together with FPs in data collection, analysis, and reporting.

Maternity Care and Buprenorphine Prescribing in New Family Physicians.

The American Board of Family Medicine routinely surveys its Diplomates in each national graduating cohort 3 years out of training. These data were used to characterize early career family physicians whose services include management of pregnancy and prescribing buprenorphine. A total of 261 (5.1%) respondents both provide maternity care and prescribe buprenorphine. Family physicians who care for pregnant women and also prescribe buprenorphine represented 50.4% of all buprenorphine prescribers. The family physicians in this group were trained in a small number of residency programs, with only 15 programs producing at least 25% of graduates who do this work.

Practice Patterns of Family Physicians With and Without Sports Medicine Certification.

OBJECTIVE: To update information regarding practice patterns of family physicians with a certificate of added qualifications (CAQ) in Sports Medicine (SM), because it has been over 10 years since the last comprehensive study. DESIGN: Cross-sectional analysis of 2017 and 2018 American Board of Family Medicine (ABFM) Family Medicine Certification and SM CAQ examination registration practice demographic questionnaire data. SETTING: N/A. PARTICIPANTS: Family physicians with a CAQ in SM [sports medicine family physicians (SM-FPs)] and family physicians without a CAQ registering for the ABFM Family Medicine Certification or SM CAQ examinations. INTERVENTION: N/A. MAIN OUTCOMES: Self-reported time spent practicing SM, activities in SM, scope of practice, and practice setting. RESULTS: Sports medicine family physicians are predominately men (78.7%) and below 49 years (65.8%). Most SM-FPs spend 60% of their time or less practicing SM and the scope of practice of SM-FPs is only slightly narrower than that of their family physician counterparts without a CAQ. In addition, 92.8% of SM-FPs are practicing in an urban setting. CONCLUSIONS: The similarity of scope of practice for SM-FPs and family physicians without a CAQ and the time spent practicing SM by SM-FPs suggests that most SM-FPs are spending a significant amount of time continuing to practice their primary specialty. Sports medicine family physicians are largely attracted to urban practice settings, most likely because of the higher likelihood of employment opportunities. Finally, factors that may be dissuading women from entering the field of SM deserve further investigation.

Associations Between Burnout and Practice Organization in Family Physicians.

PURPOSE: Burnout has been reported to be as high as 63% among family physicians and has negative effects on physicians, patients, and the medical system. There are likely structural causes of burnout, but little is known about the relationship between practice organization and burnout. Our objective was to study this association in family physicians. METHODS: This cross-sectional study uses secondary data supplied by practicing physicians from the 2017 American Board of Family Medicine (ABFM) Family Medicine Certification examination registration questionnaire, a mandatory component of registration, yielding a 100% response rate. Burnout was measured as a positive response to either of 2 validated questions measuring emotional exhaustion and depersonalization. Practice environment was measured with questions on work stressors and teamwork. Logistic regression determined independent associations between burnout and individual and practice characteristics. RESULTS: Of the 1,437 physicians included, the burnout rate was 43.7%; 33.7% worked in hospital-owned practices and 65.5% reported no ownership stake in their practice. Controlling for personal characteristics and practice organization, being in a hospital-owned practice (odds ratio (OR) = 1.68; 95% CI, 1.14-2.46) and being a partial owner (OR =1.67; 95% CI, 1.13-2.46) were positively associated with burnout. When also controlling for practice environment, no practice organization variable remained associated with burnout. CONCLUSION: Burnout in family physicians should not be attributed solely to practice organization. No single practice type or ownership status was independently associated with burnout, which indicates that any practice can attempt to mitigate burnout.

A qualitative study of trainee experiences in Family Medicine-Obstetrics fellowships.

BACKGROUND: Family Medicine-Obstetrics fellowships provide family physicians with advanced obstetrics training. No accreditation system exists for these fellowships, which leads to variable training. Variation of fellows' experiences is not well understood. Our objective is to understand the motivations, training, and overall experiences of fellows in Family Medicine-Obstetrics fellowships, which may inform opportunities for improvement in fellowship design and suggest how Family Medicine-Obstetrics fellowship-trained physicians are prepared to practice among other obstetrics providers postgraduation. METHODS: We conducted semistructured interviews with current and past Family Medicine-Obstetrics fellows between Spring 2014 and Winter 2015. We used a snowball sampling approach. Interviews were recorded, transcribed, and coded following an inductive approach to content analysis. RESULTS: We contacted 47 and interviewed 21 current and past Family Medicine-Obstetrics fellows from 15 programs from across the country. Fellowships varied in cohort size, length, co-occurring presence of obstetrics and gynecology training programs, and structure and curriculum. Interviewees were motivated to complete a fellowship because of inadequate obstetrics training in residency, or because of an interest in rural or urban underserved practice. Fellowship experiences were shaped by fellowship leadership, program structure and curriculum, and relationships with obstetricians. Some felt prepared to forge collaborative professional relationships with obstetricians. CONCLUSIONS: The diversity of fellows' experiences suggests possible avenues of improvement for Family Medicine-Obstetrics fellowships. These fellowships can prepare physicians to provide obstetric services in a variety of settings, including working in multispecialty integrated maternity care systems.

Buprenorphine Provision by Early Career Family Physicians.

Buprenorphine can be used in primary care to treat opioid use disorder, but many family physicians feel unprepared to care for patients with opioid addiction. We sought to describe preparedness to provide and current provision of buprenorphine treatment by early career family physicians using data from the 2016 National Family Medicine Graduate Survey. Of 1,979 respondents, 10.0% reported preparedness to provide buprenorphine treatment, and 7.0% reported current buprenorphine provision. Residency preparation to provide buprenorphine treatment was most highly associated with current provision (odds ratio = 13.50; 95% CI, 7.59-24.03). Efforts to increase buprenorphine training may alleviate the workforce shortage to treat opioid use disorder.

Higher Primary Care Physician Continuity is Associated With Lower Costs and Hospitalizations.

PURPOSE: Continuity of care is a defining characteristic of primary care associated with lower costs and improved health equity and care quality. However, we lack provider-level measures of primary care continuity amenable to value-based payment, including the Medicare Quality Payment Program (QPP). We created 4 physician-level, claims-based continuity measures and tested their associations with health care expenditures and hospitalizations. METHODS: We used Medicare claims data for 1,448,952 beneficiaries obtaining care from a nationally representative sample of 6,551 primary care physicians to calculate continuity scores by 4 established methods. Patient-level continuity scores attributed to a single physician were averaged to create physician-level scores. We used beneficiary multilevel models, including beneficiary controls, physician characteristics, and practice rurality to estimate associations with total Medicare Part A & B expenditures (allowed charges, logged), and any hospitalization. RESULTS: Our continuity measures were highly correlated (correlation coefficients ranged from 0.86 to 0.99), with greater continuity associated with similar outcomes for each. Adjusted expenditures for beneficiaries cared for by physicians in the highest Bice-Boxerman continuity score quintile were 14.1% lower than for those in the lowest quintile ($8,092 vs $6,958; ß = -0.151; 95% CI, -0.186 to -0.116), and the odds of hospitalization were 16.1% lower between the highest and lowest continuity quintiles (OR = 0.839; 95% CI, 0.787 to 0.893). CONCLUSIONS: All 4 continuity scores tested were significantly associated with lower total expenditures and hospitalization rates. Such indices are potentially useful as QPP measures, and may also serve as proxy resource-use measures, given the strength of association with lower costs and utilization.

Burnout and Scope of Practice in New Family Physicians.

PURPOSE: Family physicians report some of the highest levels of burnout, but no published work has considered whether burnout is correlated with the broad scope of care that family physicians may provide. We examined the associations between family physician scope of practice and self-reported burnout. METHODS: Secondary analysis of the 2016 National Family Medicine Graduate Survey respondents who provided outpatient continuity care (N = 1,617). We used bivariate analyses and logistic regression to compare self-report of burnout and measures of scope of practice including: inpatient medicine, obstetrics, pediatric ambulatory care, number of procedures and/or clinical content areas, and providing care outside the principal practice site. RESULTS: Forty-two percent of respondents reported feeling burned out from their work once a week or more. In bivariate analysis, elements of scope of practice associated with lower burnout rates included providing more procedures/clinical content areas (mean procedures/clinical areas: 7.49 vs 7.02; P = .02) and working in more settings than the principal practice site (1+ additional settings: 57.6% vs 48.4%: P = .001); specifically in the hospital (31.4% vs 24.2%; P = .002) and patient homes (3.3% vs 1.5%; P = .02). In adjusted analysis, practice characteristics significantly associated with lower odds of burnout were practicing inpatient medicine (OR = 0.70; 95% CI, 0.56-0.87; P = .0017) and obstetrics (OR = 0.64; 95% CI, 0.47-0.88; P = .0058). CONCLUSIONS: Early career family physicians who provide a broader scope of practice, specifically, inpatient medicine, obstetrics, or home visits, reported significantly lower rates of burnout. Our findings suggest that comprehensiveness is associated with less burnout, which is critical in the context of improving access to good quality, affordable care while maintaining physician wellness.

Challenges Faced by Family Physicians Providing Advanced Maternity Care.

Introduction Maldistribution of maternity care (MC) providers in the U.S. limits access to full spectrum MC services. Obstetricians are concentrated in urban areas with many rural areas reliant on family physicians (FP) to provide MC, yet fewer FPs are providing MC. The objective of this study was to understand the challenges FPs face in gaining skills in and providing advanced MC. Methods We conducted qualitative semi-structured interviews with 51 purposively sampled key stakeholders in family medicine MC (21 family medicine-OB fellowship directors, 19 past fellows, and 10 family medicine residency directors of programs with advanced MC training). Interviews were recorded, transcribed, and analyzed using an inductive approach to qualitative content analysis. Results Three primary challenges for FPs providing advanced MC emerged from the interviews. Training: most family medicine residency programs do not provide sufficient surgical OB training, so fellowship training is an important alternative for FPs to acquire such skills. Credentialing: obtaining hospital privileges to perform cesarean sections is unpredictable and highly variable by institution. Professional relationships: "turf battles" with other MC providers can limit FPs' ability to provide care commensurate with their level of training. Discussion As the predominant provider of MC in rural and underserved areas, FPs need to be supported to provide advanced MC services. Possible strategies to accomplish this include: enhanced family medicine training in MC; policy changes to address credentialing inconsistencies; and improved team-based care for pregnant women to ensure that every woman has access to high quality MC.

Solo and Small Practices: A Vital, Diverse Part of Primary Care.

PURPOSE: Solo and small practices are facing growing pressure to consolidate. Our objectives were to determine (1) the percentage of family physicians in solo and small practices, and (2) the characteristics of and services provided by these practices. METHODS: A total of 10,888 family physicians seeking certification through the American Board of Family Medicine in 2013 completed a demographic survey. Their practices were split into categories by size: solo, small (2 to 5 providers), medium (6 to 20 providers), and large (more than 20 providers). We also determined the rurality of the county where the physicians practiced. We developed 2 logistic regression models: one assessed predictors of practicing in a solo or small practice, while the other was restricted to solo and small practices and assessed predictors of practicing in a solo practice. RESULTS: More than one-half of respondents worked in solo or small practices. Small practices were the largest group (36%) and were the most likely to be located in a rural setting (20%). The likelihood of having a care coordinator and medical home certification increased with practice size. Physicians were more likely to be practicing in small or solo practices (vs medium-sized or large ones) if they were African American or Hispanic, had been working for more than 30 years, and worked in rural areas. Physicians were more likely to be practicing in small practices (vs solo ones) if they worked in highly rural areas. CONCLUSIONS: Family physicians in solo and small practices comprised the majority among all family physicians seeking board certification and were more likely to work in rural geographies. Extension programs and community health teams have the potential to support transformation within these practices.

More Comprehensive Care Among Family Physicians is Associated with Lower Costs and Fewer Hospitalizations.

PURPOSE: Comprehensiveness is lauded as 1 of the 5 core virtues of primary care, but its relationship with outcomes is unclear. We measured associations between variations in comprehensiveness of practice among family physicians and healthcare utilization and costs for their Medicare beneficiaries. METHODS: We merged data from 2011 Medicare Part A and B claims files for a complex random sample of family physicians engaged in direct patient care, including 100% of their claimed care of Medicare beneficiaries, with data reported by the same physicians during their participation in Maintenance of Certification for Family Physicians (MC-FP) between the years 2007 and 2011. We created a measure of comprehensiveness from mandatory self-reported survey items as part of MC-FP examination registration. We compared this measure to another derived from Medicare's Berenson-Eggers Type of Service (BETOS) codes. We then examined the association between the 2 measures of comprehensiveness and hospitalizations, Part B payments, and combined Part A and B payments. RESULTS: Our full family physician sample consists of 3,652 physicians providing the plurality of care to 555,165 Medicare beneficiaries. Of these, 1,133 recertified between 2007 and 2011 and cared for 185,044 beneficiaries. There was a modest correlation (0.30) between the BETOS and self-reported comprehensiveness measures. After adjusting for beneficiary and physician characteristics, increasing comprehensiveness was associated with lower total Medicare Part A and B costs and Part B costs alone, but not with hospitalizations; the association with spending was stronger for the BETOS measure than for the self-reported measure; higher BETOS scores significantly reduced the likelihood of a hospitalization. CONCLUSIONS: Increasing family physician comprehensiveness of care, especially as measured by claims measures, is associated with decreasing Medicare costs and hospitalizations. Payment and practice policies that enhance primary care comprehensiveness may help "bend the cost curve."

Comparison of Intended Scope of Practice for Family Medicine Residents With Reported Scope of Practice Among Practicing Family Physicians.

IMPORTANCE: Narrowing of the scope of practice of US family physicians has been well documented. Proposed reasons include changing practice patterns as physicians age, employer restrictions, or generational choices. Determining components of care that remain integral to the practice of family medicine may be informed by assessing gaps between the intended scope of practice of residents and actual scope of practice of family physicians. OBJECTIVE: To compare intended scope of practice for American Board of Family Medicine (ABFM) initial certifiers at residency completion with self-reported actual scope of practice of recertifying family physicians. DESIGN AND PARTICIPANTS: Cross-sectional data were collected from a practice demographic questionnaire completed by all individuals applying to take the ABFM Maintenance of Certification for Family Physicians examination. Initial certifiers reported intentions and recertifiers reported actual provision of specific clinical activities. All physicians who registered for the 2014 ABFM Maintenance of Certification for Family Physicians examination were included: 3038 initial certifiers and 10,846 recertifiers. EXPOSURES: Initially certifying physicians vs recertifying physicians. MAIN OUTCOMES AND MEASURES: The Scope of Practice for Primary Care score (scope score), a psychometric scale, was calculated for each physician and ranged from 0 to 30, with higher numbers equating to broader scope of practice. Recertifiers were categorized by decades in practice. RESULTS: The final sample included 13,884 family physicians and, because the questionnaire was a required component of the examination application, there was a 100% response rate. Mean scope score was significantly higher for initial certifier intended practice compared with recertifying physicians' reported actual practices (17.7 vs 15.5; difference, 2.2 [95% CI, 2.1-2.3]; P < .001). Compared with recertifiers, initial certifiers were more likely to report intending to provide all clinical services asked except pain management; this included obstetric care (23.7% vs 7.7%; difference, 16.0% [95% CI, 14.4%-17.6%]; P < .001), inpatient care (54.9% vs 33.5%; difference, 21.4% [95% CI, 19.4%-23.4%]; P < .001), and prenatal care (50.2% vs 9.9%; difference, 40.3 [95% CI, 38.5%-42.2%]; P < .001). Similar differences from initial certifiers were present when comparisons were limited to recertifiers in practice for only 1 to 10 years. CONCLUSIONS AND RELEVANCE: In this study of family physicians taking ABFM examinations, graduating family medicine residents reported an intention to provide a broader scope of practice than that reported by current practitioners. This pattern suggests that these differences are not generational, but whether they are due to limited practice support, employer constraints, or other causes remains to be determined.

Effectiveness over efficiency: underestimating the primary care physician shortage.

Interest in improving health care outcomes requires increasing the effectiveness of primary care. Focus on effectiveness is leading many innovative health systems to shrink primary care patient panels to strengthen relationships, and to enhance primary care teams to increase comprehensiveness. Such strategies would make primary care shortages worse than predicted, and are compounded by substantial declines in clinicians of all types choosing primary care careers. Severe primary care shortages beg for efficiency, but emphasizing efficiency at the expense of effectiveness threatens achieving the Triple Aim for health care. We cannot avoid the hard work of repairing our clinician training pipeline for primary care.